Provider Demographics
NPI:1912043282
Name:JOHNSON, WILLIAM R (DMD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4007 VALLEY VIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216
Mailing Address - Country:US
Mailing Address - Phone:502-448-0678
Mailing Address - Fax:502-448-6292
Practice Address - Street 1:4007 VALLEY VIEW DRIVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216
Practice Address - Country:US
Practice Address - Phone:502-448-0678
Practice Address - Fax:502-448-6292
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY57001223P0221X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60057007Medicaid